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Two-Needle Technique for Fibrin Glue Injection of Sacral Meningeal Cysts 2008

Interventional Spine

Avanti Ambekar, M.D.,
Cynthia Chin, M.D., ASSR Member

Excerpta Extraordinaire

Excerpta

A 45 year old woman presented with multiple post-traumatic sacral meningeal cysts from prior loculated CSF leak. Symptoms included worsening sacral pain on standing and Valsalva. CT myelogram (3/2007) and MRI (4/2007) demonstrated multiple intradural and extradural sacral meningeal cysts. The most posteroinferior cyst did not fill with contrast on myelogram and showed intermediate T1/high T2 MR signal without reduced diffusion. CT-guided cyst aspiration and fibrin glue injection was performed on 8/20/07. Two 13-gauge Jamshidi needles were advanced to the right and left S3 levels. 1.5 cc of serosanguinous fluid was aspirated from the left side. The right-sided needle was left open to air. Subsequently, one cc of fibrin glue (Tisseel) was administered via the left-sided needle with no pain induction. The injection was terminated upon observation of return of fibrin glue in the right-sided needle hub.

Cyst aspiration alone may allow fluid reaccumulation over time, due to the one-way valve communication with CSF. Fibrin glue injection results in durable obliteration of the cyst cavity. The two-needle injection technique has many advantages. Fibrin injection is typically very painful due to cyst distention. However, our patient experienced no pain during injection, since the second needle allowed control of cyst distention by equilibrating intracystic pressures with the atmosphere. The endpoint of injection is observation of fibrin in the second needle hub, that ensures complete filling of the potential cyst space for a more durable result. Also, the rate of chemical meningitis complications is lowered by allowing excess fibrin glue to flow out the second needle. The needles can be placed simultaneously under CT guidance with no increase in procedure time.

References

Zhang et al. "Percutaneous fibrin glue therapy for meningeal cysts of the sacral spine with or without aspiration of the cerebrospinal fluid." J Neurosurg Spine 7:145-150, 2007

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